Hepatitis C Transmission Among HIV-Infected Men Who Have Sex With Men Is Occurring Primarily in Men Older Than 35

An Interview With Sarah Fishman

By Bonnie Goldman

February 11, 2009

There's nothing like hearing the results of studies directly from those who actually conducted the research. In this interview, you'll meet one of these impressive HIV researchers and read her explanation of a study she presented at CROI 2009.

I'm Sarah Fishman. I'm a student at Mt. Sinai School of Medicine. I work with Dr. Andrea Branch. We did a study on acute hepatitis C transmission in HIV-infected men who have sex with men in New York City.1 We compared their behaviors, their sexual behaviors and their drug use, to a similar cohort of men in the U.K. to try to see if the behaviors of men in the New York cohort were different than men in the U.K. cohort.

Sarah Fishman

First, we looked at the demographics of the two cohorts. In our study in New York, we had 21 individuals who filled in a survey [the Danta risk factor questionnaire] on their sexual behaviors and their drug use. It was a survey similar to the survey used by the U.K. cohort.

The age of the two cohorts was very similar. The New York cohort was four years older, on average, than the U.K. cohort. The New York cohort had an average age of 40 years old, and in the U.K., it was 36. We're dealing with a group of relatively mature adults here. CD4 counts in the New York cohort were 528 on average, compared to 514 on average in the U.K. So, similar HIV status. Both cohorts had 50 to 60 percent of individuals with undetectable viral load. So, well-managed HIV in both cohorts.

In terms of the sexual behaviors that were practiced by the two cohorts, the New York cohort reported more protected oral sex -- active and passive oral sex with a condom -- compared to subjects in the U.K., although subjects in the U.K. reported more active and passive fisting. But those behaviors are not generally what we think of as behaviors that lead to transmission of acute hepatitis C, whereas behaviors that we do associate with transmission -- specifically, unprotected receptive anal sex -- was similar in both cohorts, both cohorts showing around 75 percent of the subjects participating in that behavior.

We also asked about drug use in the two cohorts. The New York cohort reported approximately 25 percent of the cohort used IV [intravenous] drugs, whereas only 3 percent of the U.K. cohort reported IV drug use. So there's definitely more of a possibility of IV drug use contributing to the epidemic in New York, versus in the U.K.

Which recreational drug are we talking about?

We can't attribute it to a specific drug, but we can say that generally, injecting drugs is a risk factor in New York, whereas it's not in the U.K., for this sort of epidemic.

Having said that, though, the men in the U.K. are more likely to use K, ketamines, non-crack cocaine, LSD and Ecstasy, whereas men in New York were not really using those drugs. They were using other recreational drugs, like marijuana, methamphetamine, GHB were common between the two cohorts. Both cohorts did not report a lot of use of crack cocaine and heroin, uppers.

But in terms of sharing drug influence, both cohorts report sharing rectal instruments and snorting instruments, but sharing injection instruments, specifically, was more common in the New York cohort.

The other interesting fact is that more men in the U.K. reported a lifetime history of a sexually transmitted infection [STI]. Almost 85 percent of men in the U.K. who were reported to be part of a cohort with acute hepatitis C transmission had a lifetime history of an STI, versus only 40 percent in New York.

Do we know the STI?

Not specifically, no, but non-specific urethritis was a lot higher in the U.K. cohort than in the New York cohort.

What are your conclusions?

In conclusion, there's a lot more recreational drug use in the U.K., which may be contributing to the slight increase in risky sexual behavior. IV drug use, though, was more common in the U.S. We definitely need more intensive screening of hepatitis C in HIV-positive MSM [men who have sex with men], especially in light of the rapid fibrosis progression that we've seen here in New York. Treatment is better in the acute phase.

Are there only two studies on this subject right now -- the one in Britain, and the one in New York?

No, absolutely not. There's another study in France, actually, and studies in Amsterdam, as well. So it's really very much a global epidemic that we're seeing. We've just only had a chance to compare to the U.K., but we'd definitely like to compare to France.

However, a difference between the study that was conducted in the U.K. and the study that was conducted in France is that I'm not aware of a control group in the French study, whereas we do have a control group in the New York group and in the U.K. group. So it's hard to identify what are the actual risk factors for acute hepatitis C transmission in the French cohort, for example.

Most of the men who were looked at, were they serosorting with other HIV-positive men? So they were having unprotected sex with other positive MSM?

We really don't have data on that specifically. We do have some data on where the men go to meet other men, and we do see a lot of Internet dating facilitation for that sort of thing. But we don't have direct data on serosorting. My gut feeling is that that's definitely contributing to it.

Are there plans -- I know you probably aren't aware of this, but -- in the Department of Health, or someplace, to do something about this?

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